1. Trigeminal Neuralgia
Mrs. Smith, aged 57, suffers from sudden, brief, severe, recurrent episodes of left-sided stabbing pain over her left cheek and forehead. She describes it as electric shock-like pains that are triggered when brushing her teeth or while eating. You suspect trigeminal neuralgia.
What other diagnoses should you consider when dealing with this suspected case of trigeminal neuralgia? List three.
- TMD – Temporomandibular disorder (worse with clenching teeth, prolonged chewing, yawning)
- Neuropathic trigeminal pain (post dental Sx / facial trauma)
- Paroxysmal hemicrania (may have migraine features)
- Pulpitis (decayed tooth with exposed dentine)
You remember trigeminal neuralgia can be either classical (no definitive etiology apart from a vascular compression of the trigeminal nerve) or secondary. What are the causes of secondary trigeminal neuralgia? List three.
- Tumor (benign and malignant)
- AV malformation
What are the two investigations that allow you to rule out secondary causes of trigeminal neuralgia?
- Neurophysiological tests
What is the drug of choice for the medical management of trigeminal neuralgia?
- 2nd line: gabapentin / baclofen
Medication has provided good relief x 4yr, but that pain control has been worse x 1yr. She has been eating with difficulty x 3wk and the symptoms are having a profound effect on her quality of life. She would like to know if there is any surgery that could provide a longer pain- free interval. List two possible interventions.
- Microvascular decompression
- Peripheral destruction techniques – cryotherapy, neurectomies, peripheral acupuncture, peripheral radiofrequency thermocoagulations
IHS def’n: ‘classical’ and ‘symptomatic’ (secondary).
- symptomatic TN have either a compression of the trigeminal nerve caused by tumors (benign and malignant) or other structural abnormalities such as arteriovenous malformations, or have multiple sclerosis (MS).
- Classical TN includes all cases with no definitive etiology identified, apart from a vascular compression of the trigeminal nerve.
2. Syncope ( transient, abrupt loss of consciousness with complete return to pre-existing neurologic function)
The paramedics bring in Mr. Stuart, age 50, who was found on the floor of his bathroom. His vital signs are: BP 160/60, HR 88, and O2 Sat of 93%. GCS 15. He is a heavy smoker and has poorly controlled diabetes. The only thing Mr. Stuart could remember was that he was hurrying to finish cleaning the house. He does not remember any prodromal symptoms nor any chest pain before the event. The physical examination is unremarkable except for a subtle cardiac murmur and a small occipital hematoma. Carotid sinus massage produces a 2 second pause with a decrease of 30 mm Hg in systolic blood pressure. Mr. Stuart is anxious because one of his brothers died suddenly, two weeks ago.
In addition to myocardial infarct/ischemia and arrythmia, list four additional cardiovascular causes for syncope.
- Hypersensitive Carotid sinus
- HoCM – hypertrophic cardiomyopathy
- Valvular dz: Aortic stenosis, pulmonary stenosis
- PE, pulmonary HTN, acute aortic dissection
- Other causes: situational, vasovagal, orthostatic HoTN, etc
In Mr. Stuart’s case, is the carotid sinus maneuver diagnostic of carotid sinus hypersensitivity? No
- Carotid sinus massage; ventricular pause >3sec or sBP decrease >=50 mmHg is diagnostic
- contraindicated in the presence of a bruit or hx of CVA/TIA in the past 3mo
An ECG shows ST-segment elevations in V1 through V3. In addition to myocardial infarction, what other diagnosis should be considered?
- Brugada Syndrome (ST elevation – saddle back configuration – in V1-V3 and/or RBBB)
- Long QT syndrome is another common inherited cardiac ion channel abnormalities (Tx with BB & ICD)
3. Plantar Fasciitis
Sandra, a 32-year-old waitress, c/o left heel pain. She has been working long hours for the last four months. She experiences excruciating pain by the end of the day. She took acetaminophen for some time, but found no relief. She has no other medical problems. She takes oral contraceptives and has no allergies.
- Name at least two pain characteristic features you should ask about.
- Pain after standing up from the bed in the morning
- Pain after being inactive (seated) for a prolonged time
- Pain improves with ambulation
- Pain intensified by walking or standing for a long time
- List at least four risk factors for plantar fasciitis.
- Obesity / BMI >30
- Sedentary lifestyle
- Prolonged standing or walking occupations (military)
- High Arch (pes cavus)
- xs foot pronation
- Tight achilles tendon and intrinsic foot muscle
- Overuse – excessive running
- Leg length descrepancy
- You notice that Sandra limps slightly. Which physical features will you look for? List two.
- Palpable tenderness at anterior medial plantar calcaneal region
- Discomfort in the proximal plantar fascia withpassive ankle/first toe dorsiflexion
- You recommend a sick leave for a few weeks and prescribe an NSAID. Four weeks later, she returns and reports some relief during treatment, but the pain recurs soon after. You order a plain radiography which reveals subcalcaneal spurs. You believe that these calcaneal spurs support the diagnosis of plantar fasciitis. True or False? False
- Which other imaging could be ordered to rule out soft tissue pathology of the heel?
- MRI / U/S (proximal plantar fascia thickness >4mm)
4. Falls in the Elderly
John Lee, 85, comes to your clinic for a regular check-up. He is currently asymptomatic. When questioned about falls, Mr. Lee states that he has fallen three times in the past year, with no loss of consciousness. His medical history includes hypertension, arthritis, dementia and depression. He takes risperidone 0.25 mg po once daily, hydrochlorothiazide 25 mg od, celecoxib 100 mg bid, oxycodone 5 mg po q four hours and donepezil 10 mg od.
- List the independent risk factors for falls in Mr. Lee’s profile.
- Previous falls
- Balance impairment, Parkinson dz
- decreased muscle strength
- Visual impairment
- Polypharmacy (>4 meds) & psychoactive drugs
- Walking difficulty, gait problems, walking aid use
- Dizziness, orthostasis, vertigo
- Mr. Lee’s medication includes five classes of medication. Which class has not been associated with falls?
- On physical examination, you notice that Mr. Lee has sinus carotid hypersensitivity. Which intervention would reduce his number of falls?
- cardiac pacing
- Which one of the following interventions does not reduce the risk of falls in the elderly?
- New eyeglasses Rx found an increased rate of falls
- (Vit D > Taichi, antislip shoe in winter, cataract surgery, pacing in cardio-inhibitory carotid sinus hypersensitivity, single-lens distance-vision glasses for outdoor all reduces the risk of falls)
5. Acute Knee Injuries
Manny McIvor, aged 44, presents to your office four days after injuring his right knee while skiing. He twisted his body and his right ski got caught on the ground. He felt a sharp pain and could not continue skiing. He reports some mild swelling and a sense of clicking in the medial knee, with episodes of locking. This prevents him from getting full range of motion. Examination reveals medial joint line tenderness, a positive ballottement test, and pain with full flexion of the knee.
- What is the most likely diagnosis?
- Medial meniscus tear
- age over 40 (OR = 4.1),
- weight-bearing during trauma (OR = 3.4),
- pain with passive flexion during examination (OR = 2.7),
- and inability to continue activity (OR = 2.2).
- unable to fully extend the knee, indicating a possible “bucket- handle” meniscal tear?
- Medial meniscus tear
- What two other physical examination tests may confirm this diagnosis?
- Positive McMurray’ test
- Positive Thessaly test
- holding the patient’s outstretched hands while he or she stands flat-footed on the floor, internally and externally rotating three times with the knee flexed 20 degrees.
- Cal Lightning, a 20-year-old university basketball player is at your office today after sustaining a right knee injury during a game last night. A teammate fell while rebounding a ball and struck Cal on the anterior aspect of his tibia, which forced
his femur to slide posteriorly on the tibia. Cal heard a pop and his knee immediately became swollen. He was unable to bear weight after the injury and needed crutches to get to your office today. What is the most likely diagnosis?
- ACL injury / tear
- What physical examination tests would support this diagnosis?
- Positive Anterior drawer’s test
- Positive Lachman’s test
- Positive Pivot shift test
- fully extending the knee and rotating the foot internally. A valgus (abduction) force is applied while progressively flexing the knee, watching and feeling for translation of the tibia on the femur
- Leah Plateau, aged 50, presents in the emergency department where you are working today. She developed knee pain after her left knee hit the dashboard during a motor vehicular accident earlier today. She was not able to walk immediately after the accident. Examination reveals a large effusion. The patient is not able to flex her knee fully and she cannot bear weight on her left leg. What is the most likely diagnosis?
- Patella / knee fracture
- Based on the Ottawa Knee Rule, should this patient have an x-ray? Yes
- age 55 and over
- inability to bear weight for four steps (unable to transfer twice) immediately after injury or in the emergency setting
- inability to flex knee to 90 degrees
- tenderness over head of fibula or isolated to patella without other bony tenderness.
6. Complementary and Alternative Medicine for Depression
Tamara is a 30-year-old woman who rarely comes in to see you. She is generally healthy, and prefers to try to take care of her health problems using complementary and alternative methods (CAM). But as you sit down, you can see that all is not well. She starts crying, relating a story about having difficulty with her relationship and a lot of work stress. She is at her wits’ end. After questioning her, it is clear to you that she has a mild to moderate depression. Not surprisingly, she declines when you offer her antidepressant medication. But she admits that she could probably benefit from some kind of intervention.
- She has heard of St. John’s wort, and wonders about possible side effects. You reassure her that side effects are generally less than with antidepressant drugs, but that certain medications must be avoided when taking it. Name three classes of medication that should not be taken with St John’s wort.
- SSRI, TCA, MAO inhibitors, antiretrovirals
- She asks about SAM-e. Read a review article about CAM treatments for depression, you assure her that it has been shown to be effective, but that it has one main drawback. Name the main drawback for the use of SAM-e.
- You ask her if she is currently taking supplements of omega-3 fatty acids. She replies that she used to but currently does not. You explain that there is evidence that omega-3 fatty acids can be beneficial in the treatment of depression. Name the most common side effect of omega-3 fatty acids.
- Fishy aftertaste
- Pt asks if there are any other lifestyle interventions that can help. Name one lifestyle intervention that has been shown to be beneficial in the treatment of depression.
7. Amyotrophic Lateral Sclerosis –
Mr. Lou, aged 50, presents with weakness of his right hand. He is right-handed. He began to notice trouble writing, opening beer bottles and turning keys about two months ago. You suspect that he has amyotrophic lateral sclerosis (ALS).
- What four signs would you look for? UMN and LMN dz in the same body region
- UMN dz
- LMN dz
- UMN dz
- What else will you include in your differential diagnosis? List four.
- Lyme dz (lyme serology)
- Heavy metal poisoning (blood & urine heavy metal screen)
- Vit B12 deficiency (Vit B12 levels)
- MS (Multiple Sclerosis) (MRI brain, evoked potentials, CSF oligoclonal bands)
- Spinal cord compression (MRI spine)
- Post-polio syndrome (electromyography)
- Myasthenia gravis (repetitive nerve stimulation, single fiber-electromyography, antibodies for acetylcholine receptors)
- Multifocal motor neuropathy / chronic inflammatory demyelinating polyneuropathy, inclusion body myositis, polymyositis, dermatomyositis (muscle biopsy, electromyography, serum CK)
- What tests should be ordered to support the diagnosis?
- Basic screening blood investigations
- MRI of the brain and spinal cord
- Nerve conduction studies
- As with many neurologic disorders, Lou’s prognosis is not good. Over the next while, who may need to be involved as you coordinate his care?
- PT, OT, social worker, Dieticians, speech pathologist
- Medical specialists, palliative care teams
- List four symptoms of ALS which often require treatment.
- Excess and think saliva
- Muscle cramps, muscle spasm / spasticity
- Depression / emotional lability
- Choking sensation, panic / claustrophobia
- morphine to relieve breathlessness and pain,
- midazolam for agitation and distress, and
- glycopyorolate bromide or hyoscine sulfate to dry up distressing chesty secretions.
8. Management of Falls in Older Persons
Shirley Macdonald, aged 86, Caucasian, is admitted to the geriatric ward for a fall which took place two days ago in her kitchen. She shows some bruises on her buttocks and upper limbs. Her medical history reveals a high blood pressure, type 2 diabetes and transient ischemic attack (TIA). She also reports that she broke her hip three years ago. Her medications include metformin 850 mg twice daily, hydrochlorothiazide 12.5 mg once daily and irbesartan 150 mg once daily. She has also been taking lorazepam 1 mg at bed time for more than ten years.
- Identify at least four non-modifiable risk factors for falls in Mrs. Macdonald’s case.
- Age >80
- Female sex, white race
- Hx of TIA / CVA
- Hx of fracture
- Hx of falls
- Arthritis, cognitive impairment/dementia/recently d/c from hospital (within 1mo)
- Modifiable Risk Factors
- Balance impairment
- Gait impairment
- Muscle Weakness
- You perform a gait and balance evaluation by using the Get Up and Go Test ( get out of a chair without the use of his or her arms (if possible), walk 10 ft (3 m), turn, return to the chair, and sit down.). It took her seventeen seconds to do it, which is slower than the timed version of the test. List two other tests to evaluate gait and balance.
- The Berg Balance Scale
- The Performance-Oriented Mobility Assessment
- Ask >65yo pt about falls & perform a gait & balance evaluation if reports a single fall
- What assessments and evaluations would you include in your physical examination? List five.
- CV exam including postural BP & HR
- Detailed gait assessment, tandem & semi-tandem stance
- Vision – assessment of visual acuity
- Evaluation of muscle / motor strength
- Neurologic evaluation: Cerebellar testings etc
- Exam feet and footwear
- Environmental assessment, including home safety
- In collaboration with a pharmacist, you identify some of Mrs. Macdonald’s drugs which could be associated with falls. List three.
- You plan to discharge Mrs. Macdonald after a four-week stay in hospital. Which multifactorial interventions would you recommend? List four.
- Exercise program with muscle strengthening & gait + balance training
- home assessment & modification
- Minimization of medications
- Management of postural HoTN
- Management of foot problems and footwear
- Before discharging Mrs. Macdonald, your family medicine resident recommends a vitamin supplement that can reduce her risk of falling. What is the vitamin supplement? Vitamin D 800IU (NNT15)
9. Abnormal Uterine Bleeding
Monica, aged 32, presents to your office complaining of heavy menses for the past four months. She complains also that her menses are sometimes as long as nine to ten days, but are still regular. She is slightly overweight, with a BMI of 29.
- Which type of abnormal uterine bleeding is this?
- Menorrhagia (ovulatory uterine bleeding)
- Which findings in patient or family history would lead you to think of an associated bleeding disorder? Name at least four.
- Family hx of bleeding disorder
- Hx of excessive bleeding with minor surgeries, eg wisdom teeth extraction, c/s, miscarriage
- Hx of Tx for anemia
- Menses lasting >7d, flooding and impairment of activities with most periods
- Which diagnoses should you keep in mind in Monica’s case? Name at least two.
- Bleeding disorder: platelet disorder, factor deficiency, leukemia, von Willebrand dz
- Advanced Liver disease
- Structural lesions (fibroids, polyps)
- Her physical exam shows some blood and a few clots in the vagina. Which lab tests would you order?
- CBC: HgB, WBC, plt
- INR / PTT
- If Monica were 20 years younger, which bleeding disorder would be considered?
- Von Willebrand Disorder
- Two weeks later, Monica is back in your office to get her results. The lab tests and the vaginal ultrasonography are normal. Which therapeutic options (other than the combined oral contraceptive) could be offered to Monica? List three non-surgical therapies.
- Tranexamic acid (antifibrinolytic that prevents activation of plasminogen)
- Progestins (IUD > oral) – must be given for 21d/month to be effective (different from Tx for anovulatory uterine bleeding)
- Endometrial ablation – hysterectomy (last resort) – only in women who doesn’t desire continued fertility
10. Malaria Prevention
Justin Voyageur, a 27-year-old chef, is at your office today because he just found out he needs to travel to Southeast Asia in two days for a “Top Chefs in The World” competition. His immunizations are up to date. He would like a medication to prevent malaria.
- What medication would you prescribe for him? (1st line drugs)
- Mefloquine (more resistance now)
- What are potential common adverse effects of this medication?
- Doxycycline: abd pain, diarrhea, photosensitivity, vaginal candidiasis
- Malarone: abd pain, n/v, elevated ALT
- What medication could you prescribe if he were going to the Dominican Republic?
- What other methods could Justin use to prevent mosquito bites? List two.
- DEET (>2mo old), bed netting, clothing treated with permethrin
- no Outing at night / dawn
Travelers should be warned that adequate chemoprophylaxis does not guarantee full protection against malaria. Seek medical attention for signs and symptoms of malaria, including fever, chills, headaches, and arthralgias.
11. Lyme Disease
Natalie Deere, a 28-year-old professor, is at your office today because she has been feeling unwell. She was recently hiking in the forest around her cottage in the Kawarthas and is now experiencing some fatigue, fever, chills, muscle aches, and headache. She is also concerned because she has a 10-cm erythematous oval rash on her right leg. It has a “bull’s-eye” appearance. You suspect that she might have Lyme disease.
- What is the name of the characteristic rash of Lyme disease? Erythema Migrans (>5cm)
- Name three other conditions that mimic this characteristic rash.
- Erythema multiforme – diffuse with mucous membrane involvement
- Tinea, spider bite
- Granuloma annulare (Lupus, RA etc) – feet and hands
- MRSA infection
- Nummular eczema / urticaria – back and hands
- What test would you consider ordering to support your diagnosis?
- Lyme (Borrelia burgdorferi) serology testing for antibodies
- What medication would you use to treat early localized Lyme disease?
- Doxycycline 100mg po bid x 14 days
- Amoxicillin, cefuroxime, azithromycin
- What preventive measures can Natalie take in the future to prevent subsequent tick bites? List two.
- Light-colored Protective clothing
- DEET – tick repellants
- Avoid areas with high tick burdens (wooded or grassy areas with a large deer population)
- Perform frequent body checks for ticks & bathing following outdoor activities
- The duration of tick attachment is a critical factor affecting the risk of transmission. After attachment, the tick feeds and becomes engorged, discharging its saliva into the bite wound. It takes 36-48 hours after attachment for B. burgdorferi to migrate from the midgut of the tick to the salivary glands.
How long the tick is attached (usually at least 36 hours) and whether it is engorged are two of the most important factors to consider when assessing the risk of transmission.
12. Initiating Insulin in Type 2 Diabetes
Mr. Simpson, aged 61, was recently diagnosed with type 2 diabetes. His medical history includes hypertension, dyslipidemia and a myocardial infarction three years ago. His current medications are ramipril 7.5 mg PO daily and atorvastatin 40 mg PO daily. His HbA1c value was 9.2% at the time of diagnosis last month. Mr Simpson denies polydipsia and weight loss; however, he has noticed polyuria in the last few weeks.
- Could insulin be considered as a first-line agent for this patient?
- Yes, first line if
- A1c >=9% in pt with newly dx DM OR
- if there is symptomatic hyperglycemia with metabolic decompensation (polyuria, polydipsia, wt loss)
- Insulin second line of not at target with metformin monotherapy
- Yes, first line if
- After your explanations on the importance of insulin for his condition, Mr. Simpson wonders which adverse effects this treatment may have. List two common concerns.
- wt gain
- less common: CHF & lipodystrophy
- Which of the following regimens is the ideal one to start with?
- Basal – adjust based on the fasting glucose level
- You choose to initiate insulin with a basal long-acting insulin. Despite dose adjustments based on the fasting glucose level, Mr. Simpson does not achieve target blood glucose levels. You discuss adding bolus insulin. How will you titrate this regimen?
- Basal bolus (rapid or short-acting) – Adjust the dose at mealtime based on the previous day’s glucose level, measured either 2hr after the corresponding meal or before the next meal.
- Combination includes insulin and oral antihyperglycemic reduces wt gain, insulin dose, and risk of hypoglycemia
13. Pelvic Inflammatory Disease
A 21-year-old woman presents to your office complaining of a two-week history of lower abdominal pain and new dyspareunia. She has had several sexual partners in the past year. Her appendix has been removed previously and a urinalysis and pregnancy test are negative. You do a pelvic exam and note cervical motion tenderness. You suspect pelvic inflammatory disease (PID).
- List three risk factors for PID.
- Multiple sexual partners (>2 in the past year)
- No barrier contraceptive use, IUD or OCP
- Recent IUD insertion
- hx of PID / STD
- Under age 25yo
- First sexual contact <15yo
- You decide to treat her empirically for PID as an outpatient. Name an appropriate outpatient antibiotic regimen.
- Ceftriaxone 250mg IM x 1 + doxycycline 100mg bid x 14 days + metronidazole 500mg bid x 14 days
- List three situations that would prompt you to admit her for treatment as an inpatient.
- Severe infection with n/v or high fever
- Tubo-ovarian abscess
- Can’t exclude appendicitis
- pt pregnant
- Can’t tolerate or didn’t respond to outpt abx
- What should she tell her sexual partners?
- Her partners need to be evaluated and treated if they have had sexual contact within 60days of a dx of PID.
- Pt and her partners should abstain from sexual intercourse until they have completed the Tx.
- List three potential complications of PID.
- Infertility from tubal scarring
- Ectopic pregnancy
- Chronic pelvic pain
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